PARENT/GUARDIAN DETAILS

MEDICAL DETAILS

I give permission for the school to seek medical /dental attention for my child as required. *

Yes

No

If there is a medical emergency, parents/carers are expected to meet the cost of an ambulance.

Do you have Ambulance Cover? *

Yes

No

Insurance Provider

Do you have Health Care Card? *

Yes

No

Health Care Card Number and Expiry *

First

Last

Medicare Number and Expiry *

First

Last

List any essential information that could affect your child in an emergency eg:- allergy to penicillin

Does your child suffer from any of the following?

Epilepsy

Migraine

Fainting

Hearing Problems

Travel Sickness

Dizzy Spells

Sleep Walking

Bed Wetting

Anxiety

Food Allergies

Other

Please specify ALL food allergies

Other - Please specify

ADMINISTRATION OF MEDICATION

Written authorisation must be provided for staff to administer any form of medication at school.

All medication required must be supplied by the parent/carers and are requested to make arrangements with the school for the safekeeping and handling of prescribed medications prior to the camp.

Informed Consent

I agree that my child's health care information will be shared with staff on a 'need to know' basis unless otherwise stated. *

Yes

No

If NO, and the information is restricted, who can be informed of your child's health care information? *

Does your child have a Medic Alert bracelet or pendant? *

Yes

No

Does your child have one or more health conditions that will require support from staff? *

Yes

No

Health Conditions

Severe Allergies/Anaphylaxis

Minor & Moderate Allergies

Diabetes

Seizures

Asthma

Activities of Daily Living

Other

Severe Allergies/Anaphalyxis - Has your childs Medical Practitioner provided a health care plan to assist the school to manage the condition?

Yes

No

Minor & Moderate Allergies - Has your childs Medical Practitioner provided a health care plan to assist the school to manage the condition?

Yes

No

Diabetes - Has your childs Medical Practitioner provided a health care plan to assist the school to manage the condition?

Yes

No

Seizures - Has your childs Medical Practitioner provided a health care plan to assist the school to manage the condition?

Yes

No

Asthma - Has your childs Medical Practitioner provided a health care plan to assist the school to manage the condition?

Yes

No

Activities of Daily Living - Has your childs Medical Practitioner provided a health care plan to assist the school to manage the condition?

Yes

No

Other - Has your childs Medical Practitioner provided a health care plan to assist the school to manage the condition?

Yes

No

Other Conditions or Needs - Please specify

A Health Care Authorisation is a plan developed in collaboration with the parent, the child’s doctor and the school. Such plans are required where staff are required to administer medication or where it is known there is a possibility that a child may have a severe health situation requiring assistance eg diabetes, seizure, severe Asthma attack or extreme allergic reaction to bee sting. If you suspect your child may require such a plan, please contact your Principal. Students with existing Health Care Authorisations only need to go through this process if details eg severity of condition, medication dosage/ frequency etc has changed since the original plan was put in place.

Will school staff require specific training to support your child?

Yes

No

If you have chosen 'YES' please discuss the type of training needed with the Principal.

PARENT DECLARATION

I agree that the information provided in this document is true and correct. I agree that if any of the information changes, I will notify the school immediately of the changes.